The flood gates open

Sometimes being busy helps. Yesterday felt like a world away, as this morning seemed as though the flood gates had opened. We were swamped. We already had full operating lists for the week (by this statement, I mean that I felt we would struggle to get all the cases already planned done this week – please don’t confuse this with the carefully planned and booked lists of the UK). And at the morning meeting, there were 4 new acute patients that sounded like they would all require urgent surgery. An adult hernia, a paediatric hernia and potentially two laparotomies. One was frankly peritonitic, so he would go first. The other, I was not quite sure what to make of. He looked reasonably ok, but had quite a large tender mass in his right abdomen, more upper than lower. We would X-Ray, USS and then decide what to do.

So to theatre. Prompt starts were required for we had a lot to get through. But then we faltered. Following on from the experience of Sunday, our lead nurse anaesthetist (who is excellent) felt that we needed to revise our anaesthetic strategy for these big laparotomies. They had struggled on Sunday to keep the patient asleep and not wriggling on the table, but using anything but a whiff of halothane (anaesthetic gas) resulted in the blood pressure to drop too much. With no long acting muscle relaxant available, they had to resort to the repeated does of ketamine.  She felt (as I did) that this contributed to the patient’s demise. Yesterday, we had discussed potential alternative options and agreed that two additional drugs (pancuronium and neostigmine) would be helpful (as the Mzungu doctor who had intubated a few patients, apparently it seemed I was also now considered the ‘lead anaesthetist’ to champion such matters). We had requested these medicines and the request had been approved, but they had not had the chance to arrive yet. After a bit of discussion (including the pros and cons of just transferring the patients to another centre), we decided to try and source the medication from the next nearest hospital. So off she went herself! How far removed this is from western practice where we have on hand first, second, third, fourth (etc) line options. Meanwhile we got on with two hernias, which we could do under spinal. If the laparotomy medication could be sourced quickly we would proceed here. If not, we would transfer the patients.

As we waited, I am delighted to say that we repaired two further hernias with mesh. Both of these were performed by each of the two local surgeons. Whilst a lot of hands on direction is still required by me (it is very much still a case of ‘painting by numbers’) we are certainly making great progress in our bid for sustainability. As we reached the conclusion of the second hernia, we received the ‘green light’ to proceed with the laparotomy. I was also pleased as having thought about our swab issue (we only have small swabs not at all suitable for laparotomy), I had reviewed the available gauze and had devised an easy way of producing larger ‘packs’ (what we would consider a ‘medium swab’ in the UK) for the laparotomy cases. I was keen to test them out.

Unfortunately, we were delayed in starting as there was a young lady with a ruptured ectopic pregnancy that needed an immediate operation. Essentially she was very quickly bleeding to death, and that trumped our bid. Ectopic pregnancy is a very common surgical emergency here – at least two or three per week it seems. I looked in during the procedure and the amount of blood on the floor was concerning to say the least. She did very well though – genuinely another life saved.

It was now quite late in the day as we started the laparotomy (4.30pm, most staff leave by 3pm having started a 06.30 or 7am), but I’m very glad we did. A young man and he had strangulated (dead) bowel in what I assume was a ‘reduction en masse’ of an inguinal hernia (a special type of internalisation of a hernia that is very bad). I think we operated in the nick of time. A small bowel resection was performed with the hernia defect ‘cobbled together’. I hope he will do very well. Sadly, during this case we were informed that the other potential laparotomy had died! Bonkers. I would be very interested to know what was amiss in his abdomen, the signs this morning did not suggest such acute catastrophe. I wonder if it was something weird and wonderful like a mycotic aneurysm (an atypical infection that causes catastrophic dilatation of a large blood vessel). He certainly seemed to decompensate very quickly. Whilst our more than ample resources in the UK would almost certainly have prevented his demise, here perhaps it might have been inevitable. Also, although no real consolation either, if we had transferred him, he would have died.

So it was a long day and a late finish. I walked back to the house after dark with a mixture of emotions, not least because I was tired. At times it feels like you are on a never-ending rollercoaster (and I’m not the greatest fan of such things). However, I walked through the door to find a supper of chapatis and curried peas greeting me (totally delicious, you have to try to believe) and a parcel from home (very exciting).